Action Required: Clinical Laboratory Improvement Amendment (CLIA) Revalidation in Provider Enrollment and Management System (PEMS)

Date: December 17, 2025

Attention: All Providers

Effective June 1, 2026: Claims without appropriate CLIA certification will be denied

Texas Children’s Health Plan (TCHP) reminds providers of the Provider Enrollment and Management System (PEMS) CLIA revalidation requirement.

Key Requirement:

• Providers performing laboratory services must have a valid CLIA certification for each billed procedure code.
• Effective June 1, 2026: Claims without appropriate CLIA certification will be denied. Other claim lines may process if requirements are met.
  • By March 1, 2026 (anticipated): TCHP plans to issue guidance to notify providers if their CLIA certification in PEMS is incomplete or incorrect. Providers must update their CLIA information in PEMS to ensure laboratory services are properly linked and processed.

Provider Types:

• All providers performing lab tests are affected.
• Independent laboratory provider types require CLIA for enrollment and will be reviewed by TMHP:
• Independent Lab/Privately Owned Lab (No Physician Involvement)
• Independent Lab/Privately Owned Lab (Physician Involvement)

Update CLIA in PEMS: Providers can update their CLIA certifications in the Provider Enrollment and Management System (PEMS) by creating a PEMS Maintenance License request and clicking the License/Certification/Accreditation page.

• Note: If a provider is within their revalidation window, they will not be able to create and submit a PEMS Maintenance License request and will need to update their CLIA certification through a Revalidation request in PEMS. Once the request has been approved the CLIA updates will reflect in the PEMS MPF.
• Guidance is available at www.tmhp.com/topics/provider-enrollment/pems/licenses.
• Updates may take up to one week to reflect for MCOs such as TCHP.

Required CLIA Information (per location/program):

• Certification Number (a.k.a. CLIA ID Number)
• Certification Code = Accreditation
• Issuer Code (License Issue Code = CLIA)
• Certification Type Code OR CLIA Lab Code
• Certification Effective & Expiration Dates

Important:

• NPI and CLIA ID must both be active.
• A unique CLIA ID is required for each testing location.
• All facilities performing lab tests must hold a valid CLIA certificate.

Address Matching Clarification:

• PEMS does not automatically verify addresses; TMHP does manual validation during enrollment/revalidation.
• HHSC confirms that abbreviations (e.g., “Street” vs. “St.”) are acceptable and compliant.
• Suite numbers do not need to match between CLIA certificate and PEMS practice location.

Billing Information for QW Modifier:

• Mandatory for procedures on CMS’s waived list if provider holds a Certificate of Waiver or PPMP.
• Must be appended to procedure codes for all applicable CLIA waived or PPM tests.
• The QW modifier indicates compliance with federal CLIA requirements.
• Providers should only appeal previously denied claims after CLIA information is updated in PEMS.

Resources:

• Texas Medicaid Providers Manual (TMPPM), Radiology and Laboratory Services Handbook: 2.1.1 Clinical Laboratory Improvement Amendments (CLIA) and 2.1.2 CLIA Requirements.
• The full list of CLIA certification specialty type codes from CMS can be found in the following link: https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/lccodes.pdf
• Previously published Provider Alert on this topic:https://www.texaschildrenshealthplan.org/news/provider-alert/clinical-laboratory-improvement-amendment-clia-requirements-related-pems

Next steps: Providers are strongly advised to share this information with their staff and ensure CLIA certifications are current in PEMS.

If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org. 

For access to all provider alerts: www.texaschildrenshealthplan.org/provideralerts.